Presentation by Elyse E. Lower, MD, University of Cincinnati and Sherry Hughes, Cincinnati Cancer Advisors
At the Total Health SEEK Color Virtual Workshop held in July 2023, a panel discussion on breast cancer disparities was presented by Dr Elyse Lower, Professor Emerita and Former Director of the Breast Cancer Program at the University of Cincinnati, and Sherry Hughes, Director of Strategic Community Engagement at Cincinnati Cancer Advisors, and a breast cancer survivor. Dr Lower began with a brief overview of some basic breast cancer statistics (Box 1). She also presented a typical breast cancer case example and gave an overview of some of the major racial disparities in breast cancer outcomes.
Box 1. Breast Cancer Fast Facts
Dr Lower cited data from a recent (2022) study by the Centers for Disease Prevention and Control which showed that, while the incidence of breast cancer (rate/100,000) was higher in White as compared with Black women (133.7 vs. 127.8, respectively), the mortality from breast cancer was actually higher in Black women (19.7, vs. 27.6, respectively). In addition, while incidence of breast cancer was lower overall in Asian/Pacific Islander women (101.3), the death rate was markedly lower, and less than half that of Black women (11.7), and Dr Lower suggested that data such as these highlight the racial disparities in outcome with breast cancer as well as other cancer. In terms of the White versus Black differences, Dr Lower further noted that, while breast cancer outcomes were nearly identical between these two groups approximately 40 years ago (1980), an approximately 14% difference in outcomes in Black versus While women was observable by 2020. She also reviewed more recent data from this year’s meeting of the American Society of Clinical Oncology (ASCO) with over 140,000 women, all of whom had early stage, estrogen receptor positive breast cancer, showing that Black women had both an increased risk for recurrence and worse overall survival as compared with White women. Moreover, despite a similar risk for recurrence overall to White women, Asian/Pacific Islander women again had a markedly reduced risk of death.
Racial Disparities: Potential Contributing Factors
Dr Lower then reviewed some of the potential contributing factors to these disparities, noting that they fall into 2 distinct categories overall, the biologic, and the non-biologic. The biologic, or “non-modifiable” factors include things like tumor biology and genetics/genomic factors, whereas the non-biologic factors include things like access to care, socioeconomic status, and educational factors. Ms. Hughes agreed that non-biologic factors were indeed a potential contributor to disparities in breast cancer outcomes, also noting a frequent lack of trust in the medical system among the Black community resulting from some of the historical injustices of the past. Dr Lower agreed, and noted that, unlike tumor biology, some of these factors may in fact be at least partly modifiable, by expanding access to care and by helping to dispel some of the myths and misconceptions that may exist in the Black community regarding healthcare.
The Role of Breast Density
Returning to the case example, Dr Lower noted that the patient had been judicious about her mammography screening, and indeed had a normal mammography just a few months prior to feeling a breast mass, and at the time of her diagnosis, the radiologist noted that she had very dense breast tissue. Dr Lower noted that this is, unfortunately, a common occurrence that women may be unaware of their breast density, and in fact women of color have been shown to have increased breast density relative to White women. She noted that increased breast density, in turn, makes mammography a less reliable screening tool (as a tumor may be obscured by large areas of dense breast tissue), and is also an independent risk factor for developing breast cancer. She also noted that, while magnetic resonance imaging (MRI) may lead to more false positives than mammography, it is a more sensitive imaging method to identify cancers in women with very dense breasts. Ms. Hughes agreed, noting, in fact, that MRI was the advanced screening method that she herself had sought out, knowing her own dense breast status and being aware of her family history of breast cancer. This advanced screening ultimately led to the discovery of her own very small breast cancer at an early stage. Ms. Hughes also noted her involvement in advocating for an Ohio bill, OH HB 371, that expands supplemental insurance coverage for advanced screening in high-risk women with dense breasts.
In terms of the non-modifiable factors, Dr Lower noted that breast tumors in Black women are often higher grade, hormone receptor negative, or triple negative, and may be of the more aggressive “basal” subtype. As such, there is often a need to determine whether there are any genetic (hereditary) factors present that may increase cancer risk, which can be evaluated through germline or somatic genetic testing. The use of such testing can provide potential targets for therapy and can improve outcomes, however, there are several barriers to genetic testing in underserved and underrepresented communities. Ms. Hughes noted that often times “women really don’t want to think about it [genetic testing] because they don’t want to have that diagnosis of breast cancer…” She stressed the importance of reaching out to rural communities, racial and ethnic minority groups, and the under- or uninsured, to not only stress the importance of early cancer detection, but also to identify patients who need genetic testing to better define their cancer risk. Dr Lower agreed, noting that, as cancer treatment becomes more individualized, it is especially important to have genetic testing discussions early, as targeted treatments can lead to greatly improved outcomes. In the case of breast cancer, for example, she noted that patients with metastatic breast cancer who have a germline BRCA or PALB2 mutation can benefit from a type of targeted therapy called a PARP inhibitor, with essentially a doubling of their survival as compared with chemotherapy (52% vs. 23%). Dr Lower further noted that PARP therapy can also be beneficial in the early breast cancer setting for patients with these types of mutations, as a means to prevent recurrence. She noted that individual tumor genomic testing (for somatic mutations) should also be performed for patients when their cancer has spread (metastatic disease), as there are other types of targeted therapies available that can improve their outcomes.
The Importance of Diversity in Clinical Trials
In the final portion of the presentation, the participants discussed the problem of underrepresentation of minority populations in cancer clinical trials. Dr Lower noted that, for Black women with breast cancer, clinical trial representation/participation is only about 3%, and that similar underrepresentation is observed across a wide range of other cancer types. Ms. Hughes agreed, noting that underrepresentation poses the risk that results of clinical trials (for example, efficacy and safety of anti-cancer drugs) may not be applicable across all populations of patients with cancer, and indeed for higher risk populations such as Black women. Some of the potential barriers to Black clinical trial participation include lack of education, lack of trust in the medical community, access to care, and treatment costs. Ms. Hughes noted that this was a part of her own motivation and advocacy work, to educate and inform, and to be a trial participant herself: “We get better outcomes, not only for yourself… but also for other women in general… when we all show up, and when we all participate…” She noted it is also important for clinicians to have discussions about clinical trials with their patients, to let them know what is available to them, and to dispel any myths or fears that patients may have regarding clinical trial participation. Dr Lower also noted the importance of recruiting a more diversified and a culturally appropriate work force for administration in clinical trials.
Summarizing the key points of the discussion (Box 2), Dr Lower proposed a three-pronged approach as a means to address some of the most important disparities in breast cancer. First, it is important to be aware that diverse populations with breast cancer may experience different outcomes. In the case of Black women with breast cancer, worse outcomes may be due, in particular, to both tumor biology as well as later stage diagnosis. Secondly, appropriate germline genetic testing for patients may be one means to improve outcomes for patients. While not all patients may elect to do genetic testing, Dr Lower suggested that the option should at least be discussed with the patient, as well as the possible implications of the results for their treatment. In addition, she suggests that somatic genetic testing (tumor genomic analysis) should be performed for all patients with metastatic disease, as a means to identify any potentially targetable mutations for treatment. Thirdly, Dr Lower suggested that partnering with patients is at least one way to enhance access to care, and to facilitate adherence and compliance with their treatment. Part of this process is encouraging more diversity in the work force, as a means to facilitate care and promote a more diverse enrollment in cancer clinical trials. Lastly, Dr Lower notes that diversity and representation matters, both in the workforce and in clinical research, and she warns that racial disparities in breast cancer outcomes could widen even further with increasing use of novel therapies, if not universally adopted, so the goal must be to achieve more equitable care for all populations in order to provide the right care at the right time.
Box 2. Addressing Disparities in Breast Cancer – Key Points
You can see the full presentation from the Total Health 2023 SEEK Color Workshop here: